World Class Hospital: World Class Hospital: sebuah program peningkatan mutu (“Urun rembug” implementasi PATH‐WHO dalam Standar Pelayanan Minimal RS) Budi Mulyono RSUP DR Sardjito/ FKUGM Yogyakarta
Dinamika Globalisasi Tekanan dari luar
( refleksi )
Pelayanan Kesehatan di Indonesia
Keadaan dalam organisasi
( perubahan )
ERA GLOBALISASI :
• Perkembangan IPTEK • Pesatnya arus informasi • Masyarakat y semakin maju j • Peraturan, UU & hukum • Tuntutan mutu pelayanan semakin tinggi
. Performance Performance Excellence (World Class Criteria)
PATH – WHO sebagai kriteria world class world class
7
8
Standar Pelayanan Minimal RS Departemen Kesehatan RI : • SK MenKes: 129/Menkes/SK/II/2008, 6 Februari 2008 • Setiap RS hrs menyesuaikan dalam waktu 2 tahun sejak ditetapkan • Terdiri dari 21 jenis pelayanan, 96 indikator dan standar yang dinilai • Rumah sakit dalam peningkatan mutu pelayanan dianjurkan sesuai dengan penerapan SPM‐RS, dapat dilaksanakan secara bertahap 9
STANDAR PELAYANAN MINIMAL RUMAH SAKIT RUMAH SAKIT 1. Pelayanan Pelayanan Gawat Gawat Darurat 2. Pelayanan Rawat y Jalan y p 3. Pelayanan Rawat Inap 4. Pelayanan Bedah / Operasi 5. Pelayanan Persalinan dan Perinatologi 10
STANDAR PELAYANAN MINIMAL RUMAH SAKIT RUMAH SAKIT 6. Pelayanan Intensif 7. Pelayanan Radiologi 8. Pelayanan Laboratorium Patologi Klinik g 9. Pelayanan Rehabilitasi Medik 10. Pelayanan Farmasi y 11. Pelayanan Gizi 12. Pelayanan Transfusi Darah 13. Pelayanan Masyarakat Miskin
14. Pelayanan Rekam Medis 15. Pelayanan Limbah RS 16. Pelayanan Administrasi Manajemen j 17. Pelayanan Ambulans / Kereta Jenazah 18. Pelayanan Pemulasaraan y Jenazah 19. Pelayanan Laundry 20 Pelayanan Pemeliharaan 20. Pelayanan Pemeliharaan Sarana RS 21. Pelayanan Pencegahan & Pengendalian Infeksi Pengendalian Infeksi 11
Clinical effectiveness and safety (7 i di (7 indicators) ) 1. Appropriateness of care pp p . Caesarean section delivery p 2. Conformityy of processes of care . Prophylactic antibiotic use for tracers : results of audit of appropriateness a. Colorectal scheduled surgery b. CABG c. Hip replacement
3. Outcome of care safety processess .
Mortality for selected tracer and procedures a. AMI b. CAP (Community Acquired Pnemonia) c. CABG d. Hip fracture e. Stroke f. Total hip fracture . Readmission for selected tracer conditions and procedures a. AMI (30 days) b. CAP (30 days) c. Asthma (24 hours) d. Asthma (24‐72 hours) e. Diabetes (24 hours) f. Diabetes (24‐72 hours) g. Hysterectomy (30 days) h. Total hip replecement (30 days)
‐ Admission after day surgery for selected tracer procedures a. Cataract surgery b Ch l b. Cholescystectomy t t c. Knee arthroscopy d Inguinal hernia d. Inguinal e. Curretage of uterus f. Tonsillectomy/adenoidectomy g. Tube ligation h. Varicose veins ‐ Return to higher level of care (e.g. from acute to intensive care) ‐ Sentinel events
Efficiency (4 indicators) 1. Appropriateness of services i f i ‐ Day surgery, for selected tracer procedures a Cataract Surgery a. Cataract Surgery b. Cholescystectomy c. Knee arthroscopy d. Inguinal g hernia e. Curretage of uterus f. Tonsillectomy / adenoidectomy g. Tube ligation h. Varicose veins 2. Productivity ‐ Length of stay for selected L h f f l d tracers a. Uncomplicated delivery b Histerctomy b. Histerctomy
3. Use of capacity ‐ Inventory in stock, for pharmaceuticals ‐ Intensity of surgical theatre use a. Elective b. Emergency 4. Financial performance ‐ No indicator in core set
Staff orientation and staff safety (5 i di (5 indicators) ) 1. Economic factors ‐ No indicator in core set N i di i 2. Practice enviroment ‐ No indicator in core set 3. Perspective and recognition of individual needs ‐ Training expenditures 4 H lth 4. Health promotion and safety ti d f t initiatives ‐ Expenditures on health promotion activities promotion activities 5. Staff experience ‐ No indicator in core set
6. Behavioural responses ‐ Absenteeism Short term/ Long term a. Nurses b. Nurses assistans 7. Staff safety ‐ Percutaneous injuries ‐ Staff excessive weekly working time
Responsive governance & environmental safety (2 i di (2 indicators) ) 1. System integration ang continuity ‐ Average score on perceived continuity items in patient surveys 2 Public Health Orientation : accsess 2. Public Health Orientation : accsess ‐ No indicator in core set 3. Public Health Orientation : Health promotion ‐ Breastfeeding at discharge 4. Equity and ethics ‐ No indicator in core set No indicator in core set 5. Enviromental concerns ‐ No indicator in core set
Patient centeredness (5 i di (5 indicators) ) 1.
Overall perception/satisfaction p p / ‐ Average score on overall perception/satisfaction items in patient surveys 2. Interpersonal aspects ‐ Average score on Interpersonal aspects items in patient surveys 3. Client orientation: access ‐ Last minute cancelled surgery Last minute cancelled surgery a. One day surgery b. Inpatient b. Inpatient
4. Client orientation : amenities ‐ No indicator in core set 5. Client orientation : comprehensiveness ‐ No indicator in core set p 6. Client orientation : information and empowerment ‐ Average score on information and p p y empowerment in patient surveys 7. Client orientation : continuity Average score on continuity of care items in of care items in ‐ Average score on continuity patient surveys
Dimensi Clinical Effective‐ ness
Safety 1. 2. 3. 4. 5. 6.
Caesarian sectio Prophylactic antibiotic Mortality Readmission Admission Day surgery Return to ICU
Efficiency
7. Day surgery 8. Length of stay 9. Inventory stock 10. Surgical theatre use
Staff Ori‐ entation
11. Training expenditure i i di 14. Excessive working hours 12. Health Promotion Budget 15. Needle stick injuries 13. Absenteeism 16. Work related injuries by type j y yp
Responsi‐ 17. Breastfeeding at discharge ve Gov’ce ve Gov ce Patient centeredness
(not collected)
Implementasi PATH‐WHO kedalam Std Pelayanan Minimal RS mungkinkah ? Bench marking Internasional RS, mungkinkah ? Bench‐marking Internasional
1. CAESARIAN SECTIO 1. CAESARIAN ‐ Merupakan tindakan operatif paling banyak di AS ‐ Inggris : 21,3 % : 21 3 % 17 % primer 17 % primer Perancis : 17,6 % WHO : target 10‐15 % Bila l < 5 % akses k pelayanan l k h kesehatan yg kurang adekuat ‐ Tujuan j positif : menurunkan resiko mortalitas p perinatal & neonatal ‐ Hal negatif : resiko operasi dan beaya lebih tinggi SPMinimal RS DepKes (5.6): standar < 20%
2. Antibiotik profilaksis: 2. Antibiotik profilaksis: • Angka global yang ideal belum dpt ditetapkan, rerata di g g y g p p , Pelayanan tersier: 10‐40 USD per hari • Jerman & Turki: 26‐28% ahli bedah tidak melaksanakan secara benar b • Bila dilakukan sesuai pedoman dapat menurunkan resiko resistensi antimikrobia resiko resistensi antimikrobia • Pengukuran: antibiotic density, % antibiotic evolution, antibiotic specificity SP Minimal DepKes belum mencantumkan, ttp upaya kebijakan penggunaan antibiotika sdh dirintis dg PPRA (Program Pengendalian Resistensi Antimicrobia) (Program Pengendalian Resistensi Antimicrobia)
3. Mortalitas • Dg penggunaan tracer, perlu harmonisasi ke ICD, bbrp nilai AHRQ: ICD, bbrp nilai AHRQ: ‐ Stroke: 10‐15% (12‐33%) ‐ CAPneumonia: 13,6% Æ CAP i 13 6% Æ Elderly: 17,6% Eld l 17 6% SPMinimal RS mencantumkan dg kriteria yang berbeda: kematian di UGD <24j (1.7)‐0,2% ; kematian di rawat inap >48j (3.8)‐<0,24% dan bunuh diri ranap jiwa(3.13)‐ 0%, kematian di meja operasi (4.2)‐<1%; kematian persalinan (5.1): Pdrh‐<1%, PE<10%, Sepsis‐<0,2%
4. Readmisi lewat IRD Asma dlm A dl 7 hari 7 h i : 1,1 – 1 1 3,0 % 30% DM dlm 7 hari : 1,1 ‐3,0 % CHF dlm 30 hari : 4,3 ‐13,0 % , , Hip replacement : 0,3 %‐1,6 % ‐ Indikasi pelayanan sub standar, 9‐48 % dapat dicegah : ‐ Edukasi d k pasien & keluarga k l ‐ Assesmen pre discharge Home care ‐ Home care ‐ Kasus Asma ‐ Readmisi < 24 jam : Prematur discharge ? Terlalu awal 24‐72 jam : Edukasi kurang baik < 30 hari : Rawat jalan yang kurang SP Minimal RS DepKes belum mencantumkan
5. One Day Surgery yang dipondokkan : 5 One Day Surgery yang dipondokkan : ‐ Berhubungan dengan kompetensi dokter, prevalensi rendah : 2, 42 % ‐ Memberi “stress” pada pasien ‐ Dapat dicegah : ‐ Edukasi pasien, seleksi pasien seleksi pasien yg baik ‐ Klinik pra anesthesi ‐ Perubahan b h teknik k k operasi SP Minimal RS DepKes belum mencantumkan
6. Readmisi ke ICU ‐ Indikasi I dik i kualitas k li ICU yang belum ICU b l adekuat d k ‐ Potensi kematian 2‐10 x ‐ Amerika A ik Utara Ut & Eropa &E : 4‐14 %, 4 14 % rata‐ t rata Global : 22‐30 %, Akademic Hospital : 0,9% Hospital : 0 9% ‐ Penyebab terbanyak: Premature discharge (22‐42%) , resiko komplikasi iatrogenic , resiko SPMinimal RS DepKes (6.1): < 3%
7. One Day Surgery Rate Merupakan prioritas dlm reformasi pelayanan RS, menunjukkan upaya penghematan resources, RS j kk h t RS yang belum melaksanakan dianggap “laggard” Gambaran dari manajemen pembedahan, G b d i j b d h penataan OK dan kompetensi profesi Keberhasilan ditunjang oleh pengelolaan nyeri dan K b h il di j l h l l id teknik anestesi UK: th ‘89/90: 34% (dari elektif) Æ / Æ th ‘94/95: 52% / SPMinimal RS DepKes belum mencantumkan
8. Length of stay 8. Length of stay • Tracer: Tracer: persalinan tanpa komplikasi, persalinan tanpa komplikasi hysterectomi • Financial burden dan nosocomial risk Financial burden dan nosocomial risk • Clinical pathways appear succesful in d decreasing length of stay, however, lower i l h f h l l.o.s. resulted in increased readmission SPMinimal RS (3.15): Ranap Jiwa < 6 minggu ( ) p gg
9. Inventory stock 9. Inventory stock • Perbekalan farmasi/obat, produk darah, dispo bedah • Cost of material management: lost opportunity cost, handling cost, damage Æ dapat mencapai 30‐40% operating cost operating cost • Days of stock: 21.29, RS kecil bisa 2 X lipat • Just in time dapat menghemat 10‐50% cost, hati‐hati d dengan “out of stock” “ t f t k” • Krn kesulitan untuk interpretasi diusulkan didrop, masuk dlm tambahan SPMinimal RS belum mencantumkan
10. Surgical theatre use: di AS paling tinggi Surgical theatre use: di AS paling tinggi membutuhkan beaya RS, dg memper‐ hitungkan jam operasional 90% sudah ideal hitungkan jam operasional 90% sudah ideal SPMinimal RS belum mencantumkan 11. Training expenditure: sulit utk membuat perbandingan internasional , perlu revisi SPMinimal RS (16,5): pelatihan > 20 jam/th Æ > 60% > 60%
12. Health promotion budget: diusulkan didrop 13. Absenteeism: sex dan umur tidak memunculkan variasi 14.Excessive working hours: critical safety indicator 15.Needle injuries: alert management 16 Work related injuries by type depression/ 16.Work related injuries by type: depression/ smoking/low back pain/ suicide 17.Breastfeeding at discharge: > 75% f SPMinimal RS belum mencantumkan
Ringkasan: • PATH‐WHO PATH WHO sebagai instrumen menuju ke sebagai instrumen menuju ke world class criteria merupakan program pencapaian performance excellence • Nick Jacobs (2008) revealing between jazz and leadership in performance gaining – creativeness and convention, muse and self‐ discipline must be expertly combined • Just remember that high performance can be emanate from spirit and kindness
Ringkasan: • Untuk Untuk kenyamanan kenyamanan dalam upaya pencapaian dalam upaya pencapaian kinerja prima , Standar Pelayanan Minimal p Rumah Sakit Departemen Kesehatan sebaiknya memasukkan indikator pokok PATH‐ WHO
TERIMAKASIH atas PERHATIANNYA
